May 30, 2013

What makes the best assistive technology?

What makes the best assistive technology? What are the criteria for assessing current assistive technologies, and for creating new ones?

Michael L. Boninger

Michael L. Boninger posed these questions to the audience at his May 16 talk in Scaife Hall, titled “And the Winner Is … Reflections on Assistive Technology,” part of the Provost’s Inaugural Lecture Series.

Boninger is professor and Physical Medicine and Rehabilitation Endowed Chair in the School of Medicine and director of the UPMC Rehabilitation Institute. He has conducted extensive research on spinal cord injuries associated with wheelchair use, especially injuries resulting from repeated transfers to and from wheelchairs, as well as brain-computer interface technologies that allow human thoughts to control robot arms. In introducing Boninger, Arthur S. Levine, senior vice chancellor for the Health Sciences and dean of the School of Medicine, said that Boninger’s work has resulted in “profound and very meaningful improvements to the lives of people affected by spinal cord injuries.”

While describing advances in assistive technology, Boninger also traced his career as a medical student at Ohio State University, a resident at the University of Michigan and a post-doctoral student at Pitt, where he joined the faculty and helped found the Human Engineering Research Laboratories (HERL), currently serving as its medical director. He also highlighted dozens of individuals who aided his career, from early teachers and mentors to colleagues and students — and Pitt leaders who pushed the University toward improvements in rehabilitation medicine education and services before Boninger arrived here.

One of his biggest accomplishments, he said, was becoming a physician despite an unpromising start. “I was a problem child in high school,” Boninger explained, displaying a copy of his high-school report card, with its smattering of C’s. “The important thing is that I did make it to the end. My mom would say, ‘It’s all right, grades don’t matter. They’ll matter at college.’”

Then, in his first semester at Ohio State, he did poorly once again — and his mother told him that grades didn’t matter there either. He persisted, pursuing an engineering major. “But I knew I wanted to be a physician from the beginning,” he said.

Later, in medical school at the same college, he saw a patient walk into the hospital for a heart operation, only to have a bad reaction to the dye used in a test performed on him.

“I watched the person’s function decline,” Boninger recalled. “About a month later he couldn’t walk but his heart was fine.” Then a physical rehabilitation doctor joined this patient’s care team. Boninger knew nothing of that specialty, but he marveled at the patient’s improvement. Now he believes physiatry, or rehabilitation medicine, is “the greatest branch of medicine” because it allows physicians to restore functional ability and quality of life.

“The best assistive technology is something people don’t think about anymore,” he said, citing eyeglasses, which improve poor eyesight without being much of a bother to the user. And while the wheelchair remains “the only prescription you’ll ever write that will take someone who is stuck in bed and turn him into somebody who is fully functional,” it is hardly as “transparent, effective and accepted” as eyeglasses, he pointed out.

In the last decade, surveys of wheelchair users asked what limited them most, particularly in public transportation. The biggest hindrance they cited was not their paralysis, but their wheelchair. Forty-four percent of wheelchair users had experienced at least one wheelchair failure in the past six months. They were stranded, injured or missed work, school or a medical appointment.

While there remains much wrong with wheelchair technology today, assistive devices that purport to help the paralyzed walk again are more troubling, Boninger said. “Can I walk again?” is of course the primary question of those with leg paralysis. However, he asked, “Is focusing on walking hurting people?” Another survey found that patients who start out attempting to walk after an injury and end up in a wheelchair have less paralysis but more pain than those whose progress goes from wheelchair to regained mobility.

Boninger asked the audience to decide which assistive technology was best among seven items.

• First was the Pro-Sock. Boninger helped develop this device at Michigan, although it never got past the prototype stage. While conducting research on peripheral neuropathy — numbness or pain in the extremities — he developed the Pro-Sock, which increased sensation in parts of the wearer’s feet.

• Boninger’s second contender was the wheelchair, which has been central to so much of his work at Pitt, especially at HERL, cofounded by Rory Cooper, FISA/PVA Endowed Chair and a Distinguished Professor in the Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Sciences.

• But wheelchair users get rotator cuff tears and other shoulder injuries, so Boninger helped develop the third contender for best piece of assistive technology: the Natural-Fit push wheel, which reduces the pain and fatigue of propelling a wheelchair.

A wheelchair user pushing for 14 minutes exceeds the daily limit the federal government puts on factory workers for repetitive motion, he notes. Boninger and his colleagues studied the causes of nerve inflammation and bone deterioration, which were common among wheelchair users. They found that there was a lot of wasted force. They decided to change the diameter of the push wheel, which hadn’t been changed since World War II. They also developed a new pushing motion — a semi-circle instead of an arc — that helped reduce strain on users as well.

When physical medicine and rehabilitation became a School of Medicine department in 1999-2000 with eight faculty members, Boninger was the research director for their one grant from the National Institutes of Health. Eventually, their researchers were able to figure out the specific forces affecting a wheelchair user’s shoulders at propulsion, and that the harder the user pushed, the more likely the user would have injuries.

“I think that’s what every medical researcher is there for — to change people’s lives in some way,” Boninger said.

• The fourth contender is the SmartWheel for the wheelchair, also developed here, whose circuitry allowed for the biomechanical analysis of an individual’s wheelchair use.

• The ReWalk, Boninger’s fifth contender, was the only one in which he was not involved. He did not hide his doubts about this device. The ReWalk puts a robotic exoskeleton around paralyzed legs, allowing the user to walk again. A woman in a ReWalk completed the London marathon, but it took her 17 days, with assistants walking behind her to replace the device’s batteries, Boninger pointed out. “If Rory Cooper had run that race in his wheelchair, he would have finished ahead of the runners,” he said.

• Then came beer — the sixth entrant in Boninger’s contest. He included it, he said, because beer helped facilitate a meeting that pinpointed which faculty to recruit to his department, leading to the development of the first study involving the implanting of brain electrodes that allowed a paralyzed individual to control movement of an object on a screen.

• Eventually, this led to the development of the neuroprosthesis, or robot arm — the seventh and final assistive device Boninger asked his audience to consider.

Since the first electrode implantation, Boninger and colleagues have demonstrated that they could help the paralyzed patient develop three-dimensional control of a robot arm, and later control it in seven dimensions — the combination of hand movements, wrist movements and grasping ability. They are on the verge of a prosthesis with sensory capabilities. “The science is here,” Boninger said.

“This is the kind of team that crosses all sorts of disciplines and can make this sort of amazing research happen,” he added. “This is the kind of team you can only find at the University of Pittsburgh.”

Indeed, he said, even with those seven assistive technologies, none is more significant than the people creating them: People are the best assistive technology of all.

“It’s this group of people who have fostered my career and fostered this department academically,” he concluded.